[esnr] Re: science and clinical practice in our organisation
- From: "Knut Berndorfer" <knut.berndorfer@xxxxxxxxx>
- To: <esnr@xxxxxxxxxxxxx>
- Date: Sat, 26 Jun 2004 18:21:56 +0200
Dear Ann, dear listreaders
I appreciate your contribution very much Ann. I think we need more
participation in dealing with these basic issues. And I agree that good
science is not the only issue to get neurofeedback accepted in different
communities. I think it is worthwile to explore that issue further.
I want to add something regarding your story about the alpha-theta trainee.
It might be an extreme case but it can happen with all powerful methods. The
history of this kind of training links it to Elmer Greens spiritual
practice - only later Peniston used it for alcohol addiction and PTSD. It is
also linked to the way of the shamance, using trance and drums and other
methods to reach altered states. The risk of deep transformations was always
known - you could get enlightened and sometimes you went crazy.
So what training would people using alpha-theta training need ? I believe
there are several pathways. When you work with "normal people" - a shaman
training or other inner path work - might be more useful than a standard
psychotherapy training (standard meaning with no knowledge or expierence of
altered states of experience ?).
So people who want any kind of alpha-theta training might need a screening
that assures that they do not fall into an "abnormal" category. Possibly
know a person who can deal with it, when some pathologic reactions show.
Which implies you need a network When doing alpha-theta training in Austria
I was working together with a psychotherapist.
Surely we had to discuss what means "normal" and "abnormal". And who judges.
That brings me back to another point in Anns message - we need much more
time to discuss - or better having a dialogue - before we move on.
Cordially
Knut Berndorfer,
The Gate Institute for Exploration and Unfoldment of Human Potential
Linz, Austria
Major Backgound, Physics and Inner Work
Present Focus: Use of Biofeedback for Stressmanagement and Optimize
Functioning for Personal Training and in Training in Organisations.
----- Original Message -----
From: "Frick, Ann" <a.frick@xxxxxxxxxxxxxx>
To: <esnr@xxxxxxxxxxxxx>
Sent: Friday, June 25, 2004 11:50 PM
Subject: [esnr] science and clinical practice in our organisation
> To the list,
>
> First let me introduce myself. I was at the original meeting that set up
the eSNR and have been at every meeting since. I am an academic who has also
been a clinician for more than a decade. I was first certified in
neurofeedback by a group that was widely respected in its time, but no
longer exists. I was also a member of a European organisation that was
founded by neurologists to raise the scientific tone of neurofeedback
practice on the continent. It also went out of existence. From this vantage
point, let me add a few observations and comments to this debate.
>
> We are at an important moment in the relation of the science and clinical
practice of NF. Here timing is everything. If good science on its own were
enough, then Barry Sterman’s work on SMR and seizures many years ago would
have meant that neurologists would at least have been trying NF before they
cut out parts of their patients’ brains as treatment for epilepsy. However,
we are in a time when technology has changed neuroscience and
neuropsychology in particular. The enormous development of imaging with its
obvious appeal to academic communities has still left the field where it has
been—stuck at the diagnosing stage. Medication treatments have not developed
at a meaningful pace and have been disappointing in many respects. That
leaves a small army of trained scientists who want to figure out how to do
something with all this technology. TMS has been one answer. NF is a very
obvious candidate as another. This is an exciting window of opportunity for
a massive shift in medical practice as we know it. However, the way we, the
NF community, conduct ourselves now will affect whether this window stays
open and how wide.
>
> The proposal that has been put forth is to create an organisation of
scientists and clinicians that will be directly involved through training,
certification, and maintenance of standards, in clinical practice in a
number of different countries and in a variety of treatment/training
settings. While I applaud the intentions 100%, I am concerned that many of
the risks involved are being overlooked.
>
> Let me briefly discuss just 2 of the risks that I hope will be addressed
before these steps are taken.
>
> Firstly, as professionals, both scientists and clinicians function by very
different rules. Scientists are looking for what, on average, can be
demonstrated to have an effect. Clinicians are looking for what might result
in a meaningful effect in an individual. This difference in perspective
makes for the basis of a dialogue between the two groups. However, there is
another difference that is more problematic for the project we are
considering. Scientists, in the course of their work, are subject to
peer-review. The results of their research is carefully read by other
scientists at the top of their fields and revised and corrected until it
meets appropriate standards. Funds are raised for research in a similar
manner. This is a very decentralised process in which no one group of
scientists is accountable for the performance of each and every member of
the profession. Scientists are not used to bearing that sort of
responsibility for each other as a group.
>
> In contrast, clinicians get their peer-review through their professional
organisations. This centralises the responsibility and makes everyone in the
organisation accountable for the actions of each of its members. The
organisation that is currently being proposed entails extreme levels of
accountability. This is a very exciting marriage of science and clinical
practice we are talking about. However, before we rush into it, I think it
is important that we consider carefully what we, both as individuals and as
members of our professions, are tying ourselves to and what we need to do to
minimise the risks during implementation.
>
> All professional organisations need to maintain standards among their
members. This includes protecting potential patients/clients from obvious
misconduct by practitioners such as sexual impropriety, intoxication during
sessions, etc. However, an organisation that undertakes to train
practitioners in its own name and certify them bears an added ongoing
responsibility that carries through each and every session that its
trainees/certificants conduct. That means each of us has something at stake
in these sessions. Does this mean that we shouldn’t train and certify in our
own name? Not necessarily. However, each scientist and clinician involved,
needs to know what the risks are and has a responsibility to see to it that
the risks are managed. What we need to know is how we are going to guarantee
that these risks do not materialise.
>
> In this regard, let me avoid the debate about clinical credentials for
work with psychotics, etc, and turn to the performance track that has been
proposed. Much of the peak performance work in our field has incorporated
alpha-theta training. It is well known in the neurofeedback clinical
community that the alpha-theta protocol can result in full-blown abreactions
that can be startling in their intensity. This is especially true for those
who have had a traumatic past. In fact, highly trained clinicians use these
reactions to help the client/patient resolve long-standing and deep-seated
issues. I saw this at close hand in work with Vietnam veterans when I did my
internship in neurofeedback at a clinic in a hospital in the state of
Georgia in the US. However, one day while I was there we had a visitor. She
was a respected medical professional who wanted to know about NF. Since she
wanted to try it, we hooked her up for a few minutes and all was fine.
Several hours later, the Director of the clinic left for a meeting in
another town. I took our visitor out to dinner, during which she proceeded
to break down sobbing and relive traumatic past experiences, including a
serious heroin addiction many years earlier.
>
> I stayed up with her all night doing the sorts of things I had spent many
hours watching qualified people do. But if I hadn’t had that training and
been available to her around the clock and if she hadn’t been such a highly
trained, qualified, and experienced person herself, the outcome might have
been much worse. There was a potential for some serious harm. I tell this
story to this list with her permission and at her urging.
>
> This happened to someone who would most often not be considered a risky
client. She had neurofeedback for 5-10 minutes and seemed absolutely fine
for several hours afterward. What would it mean to the field, and our
developing relations with the scientific community, if this were to happen
with some very high profile athlete or virtuoso musician of the type that is
currently interested in these applications? What do we need to do to train
peak performance practitioners to minimise this risk? Do we want to consider
dropping alpha-theta from the list of protocols that we sanction? I don’t
think so. The work of John Gruzelier and Tobias Egner in my department lends
an evidence basis to the protocol. However, if our group trains and
certifies the practitioner, our group will bear moral and legal
responsibility for this sort outcome. Of course, we will have insurance for
the financial side of this so that members of our Board will not be
personally liable for the actions of those they certify, and we will have to
satisfy our insurance carrier that we have adequate controls in place to
minimise the effect of such events. However, the marriage of science and
clinical practice that is being outlined here means that these sorts of
things will reflect back not only on other clinicians, but on the
scientists, who as members of our group will have declared themselves
accountable for the clinical practice of each and every practitioner that is
certified in their organisation’s name.
>
> I am not advocating that we drop alpha-theta training from our NF tool
box--just that we have adequate training, supervision, and oversight of
those who bear our certification. This includes alpha-theta as well as all
of the protocols and modalities for which we train and certify. One of the
most sensible approaches I have heard comes from our colleagues in Holland
who practice a form of supervision called ‘Introvision’. Perhaps others in
Europe do as well. Practitioners in an area meet regularly and discuss
cases. In that way, all are helped to maintain standards and there is some
oversight if someone begins to stray from best practices. Wytze van der
Zwaag discussed this practice at the first e-SNR training in Portugal 2
years ago when he led the group in a discussion of Ethics. I highly
recommend that he be asked to repeat his presentation at our next meeting.
If we are to construct a very centralised structure that puts training,
certification, and maintenance of standards in one organisation of
scientists and clinicians, I think we need to look seriously at the
decentralised ways that we will organise this process day-to-day.
>
> Another area of risks is much less dramatic, but may be more difficult to
deal with, and it may have even more potential to seriously disrupt
scientific-clinical relations for a long time to come. In this regard:
>
> ‘Evidence based’ is not a badge an organisation wears, but a process to
implement. What constitutes the specific levels of evidence that exist? What
type of studies have there been? How many of them? Exactly what has been
tested in the studies? In the course of putting together the ADHD/NF study
at Imperial College in London, we have learned that there is very little
agreement on anything related to the actual conduct of NF sessions. Almost
all agree that it requires more than 20 sessions and that we use sensors
placed on the head and computerised feedback based on real time EEG data.
Other than that, everything else is controversial. This includes training
sites, frequencies to train, montages, training contingencies, etc. And this
is for the protocol that has more evidence-basis than any other in the NF
field! In fact, it has been decided recently in our department that there is
not enough scientific validation for us to be able to say that QEEG is not
"electronic phrenology."
>
> What will we teach in our training courses? Will we teach only that which
a committee of scientists and clinicians formally rule as efficacious? Or
will we teach methods that we consider worthy of further investigation, but
are not yet fully evidence based? And how will be sure that
trainees/certificants know the difference? It will do great harm to the
field if individuals with our certification stray from the organisation’s
ruling as to what is evidence-based and what isn’t. For example, this means
that clinicians will have to have a signed consent form for training with
experimental treatment for any protocol that the organisation has not
explicitly ruled evidence-based.
>
> And what about claims made for NF and/or the other modalities that are
being considered in the remit of this organisation? What will we do if
members of our organisation make grand claims about NF that are beyond those
that our organisation rules as evidence-based? Over-hyping of NF has been
and continues to be one of the areas that most damages our scientific
credibility.
>
> For all of these reasons, I am glad the Board has decided that training
will be delayed until the longer term so that we can have a chance to work
out what the training will be and how we will adequately assess those we
certify.
>
> I am very heartened to read the messages that have been sent to this list.
I think that people across Europe are seriously discussing important issues,
and I hope this list will continue to be open beyond this current debate. I
think it is very important that Europe have a strong neurofeedback
organisation. I think it is a courageous decision to merge science and
clinical practice in the format that is being proposed, with scientists
accountable for the clinical practice based on their work. However, I am
especially concerned that everyone involved understand the ramifications of
these decisions and that the ground work that is absolutely essential for
this organisation to succeed be done properly.
>
> For these reasons, I formally move that we strike the section in the
proposal from the Board regarding international membership. I think that it
is crucial that the ground work be properly constructed so that the
organisation will have most effective oversight and the greatest ability to
proactively adjust our developing policies as we fine tune them. It will be
no small feat and will require extensive debate and participation as well as
many, many hours of unpaid, tedious labour from our Board and committee
members. I think that the challenge is large enough in Europe alone. If we
are spread too thin and are unable to maintain our standards, then I am
afraid that this new organisation will join the others before it that have
passed out of existence. In the meantime, we may have done some harm to
field of neurofeedback and self-regulation in general.
>
> Respectfully,
>
> Ann Frick
>
>
>
>
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